EAT OR DIE, Part II: THE EXTREME STAGES OF ANOREXIA
by Harvey Widroe, M.D.
American Reporter Correspondent
ORINDA, Calif. -- Debbie, sitting across from me in loosely fitting sweats and a bulky padded jacket - way out of place on a fairly warm day - looked very young for a 17-year-old. Although lost in oversized clothing, Debbie was actually hiding something. But just what she was hiding is perceived differently by each of us.
To Debbie, the bulky clothing concealed the body of a walrus. She had seen the fat blob in the mirror that very morning and every other morning, too. Her losing twenty-five pounds over the past year hadn't altered the walrus self-image, but to me - even though I had seen many patients like her over decades of clinical work - seeing Debbie for the first time was a shock. She was hiding a body that had become a skeleton barely covered by tight-fitting skin.
I wanted to ask her to take off the oversized jacket, but didn't. At least not during this session, our first interview. Had I done so, I knew it would only have served to increase Debbie's already intense sense of shame about her fat body self image; and the prospect of her returning for additional appointments to see me, already a low probability, would have been further diminished. If the opportunity came, some other time, I would ask her to remove her jacket. I could count on her wearing it in the future like some kind of uniform - a cloak intended to make her almost invisible.
Debbie also kept her left hand hidden. She covered it with her right hand or pulled down her left sleeve so that I could see only the fingertips. But I got a quick glimpse of the marks on the back of her left hand just above the tops of her index and middle fingers; half purple bruises and half the silvery color of old scars. These characteristic tell tale signs themselves can identify someone with a severe eating disorder, marks caused by the back of the hand repeatedly scraping and pressing against the upper teeth while trying to induce vomiting.
Some patients, more trusting and talkative about their problem than Debbie, refer to a "sweet spot" at the back of their throats where, with just a simple touch, they can set off the vomiting reflex. The term "sweet spot" to induce vomiting seems grossly inappropriate; yet to these patients the "sweet spot" becomes a familiar friend, someone you rely on to provide comfort on demand. The inescapable conclusion is that most patients with eating disorders come to actually enjoy the act of self-induced vomiting!
I felt certain that getting Debbie to her first appointment with a psychiatrist had been grueling for her parents. They would have had to almost literally pull her out of the car. How would any of us feel about coming to a doctor's office for a condition we were certain we didn't have? Debbie insisted that she didn't have any kind of eating disorder. Her major problem, she thought, was bonkers parents who wanted to control every aspect of her life - especially her eating.
More likely, Debbie would have wanted to see me had I been some sort of a diet doctor, plying her with diet drugs and "secret" calorie-burning food supplements intended to speed up her weight loss. But as far as she was concerned I was an anti-diet doctor, her parent's choice of a doctor who would try to fatten her up; from Day I, the doctor was the enemy, to be regarded with distrust.
As when she walked into my office for our initial meeting, Debbie's legs looked like sticks. Protruding above the jacket, her skull-like head barely balanced on her spinal column, the virtual absence of neck muscles giving her the appearance of a bobble-head doll. Had she taken off the jacket I would have seen that her body had no breasts, no stomach, no buttocks - all victims of the soft tissue and muscle atrophy that follows severe protein deprivation. Debbie looked like a concentration camp victim, but the agent of her starvation was not a concentration camp guard. It was Debbie herself.
Occasionally I spot one of these eating disorder sufferers like Debbie walking down the street or in a shopping mall, and I shudder; not because they appear grotesque, but because I know how dangerously they are living. They hear warnings from a chorus of others, but typically don't get the message. Yet they are actually candidates for slow or sudden death.
It is impossible to ascertain how many deaths are secondary to anorexia or bulimia. I have been unable to research any solid statistics. Five to twenty percent is the usual figure given. Some studies try to measure eating disorder deaths over a lifetime. Other identify specific populations such as deaths before age 25, or deaths amongst ballet students. Some numbers include eating disorder victims who commit suicide. In a way all of the deaths from eating disorder are a kind of suicide, death at one's own hand whether intentional or not.
Death certificates are most likely to say that the deceased died of heart failure or kidney failure or an infectious illness. Some record an overdose of a diet drug as an accidental death. What happens in most of these cases is that frequent vomiting or diarrhea or self induced starvation produces an electrolyte imbalance with a potassium deficiency. The potassium imbalance in turn can cause an abnormal heart rhythm that cannot be sustained - ventricular fibrillation. The outcome is almost always sudden death.
In anorexia without vomiting, we see a slower form of suicide. In self-induced starvation patients become slow in thinking and action, with accompanying withdrawal, depression, and inertness. Finally, in an emaciated state, as if staring off into another world, this terminal state, marasmus, is treated only with heroic medical measures.
What would happen to Debbie? Would she go on to die? At this point she didn't acknowledge to me, or even to herself, that she had an eating disorder. She just wanted to look thin and beautiful while the rest of her world, at least her parents and doctors, wanted her to remain pig-like and ugly. Unchecked, Debbie was a candidate for disaster.
To help Debbie and other eating disorder victims requires insight into a number of factors that lead into this needless and dangerous gauntlet, flirting with death at an early age. Over the next few columns we'll explore the causes and some successful treatments for these eating disorders, and then we'll look into other issues involving suicide and antidepressant drugs. Harvey Widroe, M.D., is a practicing psychiatrist and author of a recently published book "The Smart Dieter's Cheatuing Guide: Eat and Watch Pounds Melt Away," with Ron Kenner (Outskirts Press, 2007).